Provider Demographics
NPI:1043609415
Name:VESTAL HEALTHCARE, LLC
Entity Type:Organization
Organization Name:VESTAL HEALTHCARE, LLC
Other - Org Name:CORAM DIALYSIS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BARRY
Authorized Official - Middle Name:L
Authorized Official - Last Name:BLANTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:781-699-9000
Mailing Address - Street 1:1500 MIDDLE COUNTRY RD
Mailing Address - Street 2:
Mailing Address - City:CENTEREACH
Mailing Address - State:NY
Mailing Address - Zip Code:11720-3500
Mailing Address - Country:US
Mailing Address - Phone:631-716-8758
Mailing Address - Fax:631-716-2423
Practice Address - Street 1:1500 MIDDLE COUNTRY RD
Practice Address - Street 2:
Practice Address - City:CENTEREACH
Practice Address - State:NY
Practice Address - Zip Code:11720-3500
Practice Address - Country:US
Practice Address - Phone:631-716-8758
Practice Address - Fax:631-716-2423
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FRESENIUS MEDICAL CARE HOLDINGS, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-01-22
Last Update Date:2023-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY261QE0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY04286417Medicaid
NY332724Medicare Oscar/Certification